Basic Information
| Provider Information | |||||||||
| NPI: | 1164068268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKELSON | ||||||||
| FirstName: | ESTHER | ||||||||
| MiddleName: | YOON | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2146 CLINTON AVE APT B | ||||||||
| Address2: | |||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945016604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062091678 | ||||||||
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| Practice Location | |||||||||
| Address1: | 411 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946105022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108444097 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2019 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 161968 | MT | N | Nursing Service Providers | Registered Nurse | 163W00000X | 95154363 | CA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 95013748 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 161969 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1164068268 | 05 | MT | MEDICAID |